Metro Tuguegarao ILHZ

Republic of the Philippines

DEPARTMENT OF HEALTH
CENTER FOR HEALTH
DEVELOPMENT
Cagayan Valley

Local Health Support Division

Provincial Health Team Office
METRO TUGUEGARAO INTER-LOCAL HEALTH ZONE
(DRAFT)
(Drafted January 28, 2010)
ADMINISTRATIVE ORDER
No. 001, s. 2010
SUBJECT: Policies and Guidelines on Referral System for Metro Tuguegarao ILHZ
I.

BACKGROUND AND RATIONALE:

(Government hospitals) Health Facilities are not supposed to refuse patients. However,
there are instances when a particular patient cannot be handled in such hospital because it
has no equipment necessary for its management and many other reasons that would be for
the better treatment of the patients. But transferring patients entails a lot of administrative
procedures. It has been noted that in some cases, transferring patients from one hospital to
another result to complications and to the detriment of the patient. To address these
concerns, these guidelines are issed to ensure that proper procedures are followed in
transferring Emergency Room (ER) patients as well as referrals of admitted patients.
Referral system is an integral part of the Inter-Local Health Zone (ILHZ). The movement
of people through the health system of the ILHZ will depend on the REFERRAL
MECHANISM. Rationale:
1.1 The most common to the most complicated and life threatening diseases require
different levels of health workers and health care facility
1.2 Maximizes limited resources
1.3 Avoids duplication of services
1.4 Promotes cooperation and complementation of primary, secondary and tertiary health
facilities
1.5 Appropriate level of care is made available considering geographic factors, time, cost
and urgency
1.6 Promotes continuity/ sustainability of treatment/ health care

II.

DEFINITION OF TERMS
II.1 Referral System-is a set of activities undertaken by a health care provider or facility
in response to its inability to provide the necessary intervention of patients need. It
includes referral from the commuinity to the highest level of care and within the
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hospital/RHU internal system. It is a two-way relationship that requires cooperation,

coordination and exchange of information between the primary health facility and the
first referral hospital during the referral and discharge of patient from the hospital.
Referral system delineates the levels of diagnostic, surgical and medical services
appropriate for the referral hospital and other health service providers in the ILHZ.
II.2 Emergency Room Patients-are patients being evaluated and managed in the
emergency room but are not yet admitted
II.3 Inpatients-are admitted patients in the wards or private rooms
II.4Health Center Main institution linking the health services to the community
Frontline facility capable of providing preventive and curative services more
advanced than those achieved through community health action but less
sophisticated than those available in hospitals
Has a team providing a range of services and may or may not have a doctor
II.5Hospital A health facility for the diagnosis, treatment and care of individuals suffering from
illness or disease, injury, deformity, need of surgical, obstetrical, medical or
nursing care
II.6 Service Capability/Capability of Hospitals-refers to the ability of the hospitals to
manage cases based on their type of hospital, accreditation of departments,
subspecialties, manpower, equipment, etc.
Levels of care:
1. PRIMARY CARE HOSPITAL (AMH,BMH,BCH)
Non-departmentalized hospital that provides clinical care and management of the
prevalent diseases in the locality; has much more than just a curative function in
an ILHZ;
two main functions:
external-relationship w/ the community, has the capacity to interact
w/ community members and their organizations on health matters
in the catchment areas served
internal-clinical services, training function
Clinical services include general medicine, pediatrics, obstetrics and gynecology,
surgery and anesthesia
Administrative and ancillary services (clinical lab, radiology, pharmacy)
Nursing care for patients who require intermediate, moderate and partial category
of supervised care for 24 hours
2. SECONDARY CARE HOSPITAL (TCPGH)
Departmentalized hospital that provides clinical care and management on the
prevalent diseases in the locality, as well as particular forms of tratment, surgical
procedure and intensive care
Clinical services provided in primary care, as well as specialty clinical care
Administrative and ancillary services
Nursing care provided in primary care, as well as total and intensive skilled care
3. TERTIARY CARE HOSPITAL (CVMC)

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4.

5.

6.

7.

Teaching and training hospital that provides clinical care and management on the
prevalent diseases in the locality, as well as specialized forms of treatment,
surgical procedure and intensive care
Clinical services provided in secondary care, as well as sub-specialty clinical care
Administrative and ancillary services
Nursing care provided in secondary care, as well as continuous and highly
specialized critical care
INFIRMARY
A health facility that provides emergency treatment and care to the sick and
injured, as well as clinical care and management to mothers and newborn babies
BIRTHING HOME
A health facility that provides maternity service on pre-natal and post-natal care,
NSD and care of newborn babies
ACUTE CHRONIC PSYCHIATRIC CARE
A health facility that provides medical service, nursing care, pharmacological
traetment and pyschosocial intervention for mentally ill patients
CUSTODIAL PSYCHIATRIC CARE FACILITY
A health facility that provides long-term care, including basic human services such
as food and shelter, to chronic mentally ill patients

2.8 Packages of Services-The rationale for defining essential packages of health care
services for the ILHZ is to ensure that the limited health resources are targeted towards
provision of essential health activities. This results in improved health status of the
community and the cost-efficient use of health care resources. Another reason for setting
minimum and complementary packages of services at all levels is to ensure appropriate
services are provided at different levels of the referral facilities.
THE PACKAGES OF ESSENTIAL SERVICES
A Minimum Package of Activity (MPA) for primary health care services
A Complementary Package of Activity (CPA) for core referral hospitals; and
A Tertiary Package of Activity (TPA) for the provincial government referral hospital

Minimum Package of Activity for Primary Health Care Services (BHS, RHU)
Pre natal care
Normal delivery and post partum care
Immunization
Family planning
Nutrition (vitamin a and iron supplementation
Growth monitoring
Control of communicable diseases (e.g. ARI, TB, DD, STD, malaria)
Control of non-communicable diseases (e.g. related to diet , alcohol, tobacco)
Minor surgery (e.g. suturing, drainage of abscess, circumcision)
Dental health
Appropriate referral to referral hospitals or specialist physicians
Environmental health services
Basic laboratory services
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Health promotion and education

Management of public health services, coordination with non-government organizations
(NGOs) and the private medical sector, participation in ILHZ management
Training of human resources
Supervision of health services and human resources within the municipal catchment area
Complementary Package of Activity for Core Referral Hospital (PGH, AMH, BMH, BCH)
Outpatient consultations for patients referred from the primary level
In patient medical and surgical care
Emergency room care
Minor surgery (caesarian section, trauma surgery, appendectomy)
Complicated deliveries
Basic orthopedics (e.g. setting of simple fractures)
Nutrition services
Referral of more urgent cases to a higher level of care
X-ray (TCPGH only)
Laboratory services
Blood transfusion
Pharmacy services
Management of hospital services and participation in ILHZ management
Public health promotion and education
Coordination with public health services, NGO and the private medical sector
Transport and communication linkages with other levels of care
Medical Social Services
Tertiary Package of Activity for Provincial Government/DOH Retained/End Referral
Hospital (CVMC)
Pediatric, surgical, medical, orthopedic, obstetric and gynecology departments)
Expanded surgical capability (e.g. craniotomy, orthopedics, burns)
Intensive care, neonatal intensive care, coronary care
Ophthalmology
Rehabilitative medicine (physiotherapy, occupational therapy)
A full range of dental services
Advanced diagnostics (e.g. x-ray, ultrasound, laboratory)
Public health laboratory (e.g. malaria, schistosomiasis, water analysis, referral laboratory
for RHUs and core referral hospitals)
Blood bank and transfusion services
Medical social services, veterans and senior citizens medical services
Pharmacy services
Dietary and nutrition services
Wellness Center Program
Hospital administration and management services
Emergency transport
In-house engineering and maintenance
III.

GUIDING PRINCIPLES
This policy framework is guided by the following principles:
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III.1
Republic Act 8244: An act penalizing the refusal of hospitals and medical
clinics to administer appropriate medical treatment and support in emergency or
serious cases, amending for the purpose Batas Pambansa Bilang 702, otherwise
known as An act prohibiting the demand of deposits or advance payments for the
confinement or treatment of patients in hospitals and medical clinics in certain cases.
Salient Features:
In emergency or serious cases, it shall be unlawful for any employee of the
hospital to request, solicit, demand or accept any deposit or any other form of
payment as a prerequisite for confinement/medical treatment or to refuse to
administer medical treatment and support to prevent death or permanent
disability
When the patient is unconscious, incapable of giving consent or
unacompanied, the physician can transfer the patient even w/o his consent
provided that such transfer can be done only after necessary emergency
treatment and support have been administered and that it has been established
that there is less risk to transfer patient than continued confinement
No hospital or clinic after being informed of the medical indications for such
transfer, shalll refuse to receive the patient nor demand any deposit or advance
payment
After the hospital or medical clinic mentioned above shall have administered
medical treatment and support, it may cause the transfer of the patient to an
appropriate hospital consistent w/ the needs of the patient preferably to a
government hospital; specially in the case of poor indigent patients
III.2
The policy framework is a response to Administrative Order No. 5-B, s.1998
Salient Features:
TRANSFER OF PATIENTS
*The transferring and receiving hospital shall as much as practicable be within 10km
radius of each other
*The transfer of patients contemplated under this act shall at all times be properly
documented.
*Hospitals may require a deposit or advance payment when the patient is no longer
under the state of emergency and she or he refuses to be transferred
*Hospital and clinic managers shall instruct their personnel to provide prompt and
immediate medical attention to emergency and serious cases w/o any prior
requirement for any deposit or payment.
*All hospitals shall use a Uniform Discharge/ Transfer Slip for cases covered by RA
8244 which shall include the following information:
Admission Form of transferring hospital
Transfer Form of transferring hospital to include but not necessarily limit ot
the following information: vital signs, name of Attending Physician, treatment
given to patient, name of receiving hospital, name of contact person and
approving official at receiving hospital
Consent of the pt/companion-In case of an unaccompanied minor patient, they
may be transferred w/o consent provided that the provisions of RA 8244 is

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strictly observed. The hospital shall endeavor to use all forms of media to
contact the next of kin of the unaccompanied minor patient
In case of refusal of transfer, the name of the hospital, the name of person who
refused and the reasons for the refusal

IV.

PROGRAM GOALS AND OBJECTIVES

4.1 General Objective:
The overall objective is to improve the referral system of health facilities in the ILHZ of
Metro Tuguegarao from the community to the primary (BHS,RHU), secondary
(Municipal/District Hospital) or tertiary (Provincial Hospital, Medical/Regional Center)
level of care.
4.2 Specific Objectives:
Minimum package of services at the primary facilities and complementary
services at the secondary and tertiary facilities determined
Appropriate referral form, referral flow, recording, reporting and monitoring
forms standardized
Policies and guidelines on the referral system of the ILHZ implemented

V.

COVERAGE AND SCOPE

V.1 This policy shall cover the whole health care delivery system that includes hospitals
and public health facilities whether government or private of the entire Metro
Tuguegarao ILHZ; in the event that there will be additional health facilities within the
cluster, they shall automatically be covered under these regulations.
V.2 Hospitals, Health Facilities and other Inter-Local Health Zones who wish to follow
this procedure shall coordinate with the Technical Management Committee and
Governing Board of Metro Tuguegarao ILHZ.

VI.

GENERAL POLICIES / GUIDELINES ON REFERRAL SYSTEM

VI.1
Local centers (BHS/RHUs) should be promoted as an entry point into the
health care delivery system; referral flow: pls see attached annexes
VI.2
Patients should not be refused at any level of the referral system. However,
they should be evaluated and thereafter referred to the appropriate facility;
VI.3
Active community participation is required for a successful referral system.
This should include NGOs, Peoples Organizations (POs), Brgy Officials, BHWs and
other community groups;
VI.4
All participating agencies/ communities should be aware of each others
capabilities in an up-to-date manner (service capability, service fees, etc);
VI.5
The referral system should not be interpreted as an assurance that free
medicine and services would be provided; however, charges shall be collected to
maintain hospital operation and the high cost of facility upgrading;
VI.6
Patients need health care providers guidance in the proper use of health care
resources and thefore community awareness regarding referral shall be strengthened ;
VI.7
Practice professional ethics. Respect each others management decision ( if
correction is necessary, do so discretely);
VI.8
Patients welfare is the primary consideration in referral system;
VI.9
Confidentiality must be practiced at all times at all levels;
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VI.10
A two-way referral must be observed;
VI.11
Hospital and field health personnel are expected to maintain proper decorum
at all times in relating with patients, patients relatives and co-employees;
VI.12
Supervisors shall orient and train all hospital and field health personnel in the
operations of the comprehensive referral system, in the area of ILHZ;
VI.13
Coordination and teamwork among all health providers shall serve as a
common approach to attain goals and objectives;
VI.14
Services to be rendered to a patient shall, depend on the facilities, its
capabilities, and manpower resources;
VI.15
Referral system shall take into consideration the general welfare of the patient
and the capabilities of the facilities within the system;
VI.16
Tasks at any level of health care facility shall be clearly defined, mutually
understood, and reasonably qualified. Actual performance shall also be evaluated
regularly;
VI.17
All patients shall be attended to immediately upon arrival, giving preference to
emergency cases/ or seriously ill patients;
VI.18
Clear, written health referral policies and guidelines shall be available in all
health facilities. Standard referral forms must also be available at any given time;
VI.19
Essential drugs and medicines shall always be available in all health facilities;
VI.20 Services not currently available shall be accessed from the next level of care;
VI.21 Patients who have been referred must be sent back to originating facilities for
follow-up and disposition;
VI.22 Cluster barangays and municipal health care units refer patients to the core
referral hospital of the ILHZ where they belong, unless services are not available in
that area;
VI.23 Patients may be transported to and from health facilities using a service
ambulance or other means of transportation. Ambulance fee must be determined by
the ILHZ and charged accordingly based on the patients ability to pay;
VI.24 Communication system must be in place to facilitate the referral;
VI.25 In areas or ILHZ where there is no government hospital, networking with private
hospital facilities with available services shall be developed;
VI.26 Available services at each facility shall be determined and a Memorandum of
Agreement (MOA) between the private and municipal and provincial government
should be undertaken;
VI.27 Continuous training and updating of capabilities of the health service providers
shall be utmost consideration;
VI.28 A separate logbook shall be maintained for monitoring and evaluating records of
all patients; and
VI.29 Each level of health care unit shall have a list of essential equipment.
VII.

INSTITUTIONAL POLICIES/GUIDELINES

In conformity with national policies, and with concurrence of the local health board, supporting
issuances shall be available in the following areas:
VII.1
Technical Policies:
-accidents/gunshots wounds/stab wounds
-action on rape case
-alcohol verification/drug test policy
-medical physical exam
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Conduct of autopsy
-autopsy examination
-post-mortem examination
7.2. Administrative Policies
Networking of health facilities within the ILHZ
Use of vehicle (e.g. ambulance)
Transport of patient
Extension of services outside catchment area
-management of medico-legal cases
-issuances of medical certificates
-attendance to court hearing of medical-legal cases and
-incentives for using appropriate facilities (e.g. higher user fees for using
inappropriate health facilities
VIII. POLICIES ON MEDICO-LEGAL CASES
VIII.1 As a general rule, all MHOs shall act as medico-legal officers in their
community in the absence of the provincial medico-legal officer;
VIII.2 All requests for medico-legal examinations must be accompanied by an official
request from the police authorities of the concerned municipality or barangay;
VIII.3 Medico-legal requests not within the capability of the MHO concerned should be
referred immediately to the NBI together with corresponding reasons for referral;
VIII.4 In cases where the MHO of the area concerned is out-of-town and after all
efforts to locate him/her been exhausted, the hospital within or the MHO or hospital
of the nearest municipality within the ILHZ must perform the requested examination;
VIII.5 (All) Medico-legal cases shall be the responsibility of the MHOs, unless the
patient would require the services of the hospital for further evaluation and treatment.
During weekends and holidays, the hospital can attend to medico-legal patients;
Medico-legal cases requiring surgery (in absence of accompanying) consent will be
signed by attending physician;
Blood transfusion may not be given when it becomes a religious issue (waiver should
be signed by patient);
VIII.6 Transport vehicle to fetch the MHO must be provided by the requesting parties
concerned. If (autopsy) post-mortem examination is conducted in a private setting,
the MHO should be escorted by a police officer;
VIII.7 Medico-legal fees shall be paid to the MHO based on the rate provided by the
MAGNA CARTA for PUBLIC HEALTH WORKERS. This policy is, however,
subject to the availability of funds and the usual accounting and auditing rules and
regulations;
VIII.8 In some instances where there are no MHOs available in the area or ILHZ
concerned, the Provincial Health Officer (PHO) may, upon prior notice, direct any
government physician, preferably with expertise on the case, to perform the required
examination. This is, however, subject to the presentation of a certification from the
office of the LCE concerned that the MHO is not available; and
VIII.9 All other policies not included herein in relation to the above-mentioned subject
matter shall be referred to the Provincial Health Officer for evaluation and approval
and subsequent inclusion in this general policy guideline on referral of medico-legal
cases.
IX.

GENERAL GUIDELINES IN THE EMERGENCY ROOM

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The Emergency Room is considered the show-window of the hospital and as such
reflects the management of the entire hospital. It should be the responsibility of the
Chief of Hospital to ensure that enough manpower and equipment are available to
meet the emergency needs of every patient. Some reasons fro transferring the patient
is primarily internal problems in the Emergency Room. As such the following policies
shall be followed:
IX.1
All hospitals having departmentalized services should exercise some form of
autonomy in the Emergency Room. Nurses and administrative staff should be
permanently assigned to the Emergency Room so as not to disrupt the services and to
provide continous training skills competencies in emrgency care; residents and interns
should have a fixed time frame of rotation e.g. 2-3 months and not pulled out anytime
by the different departments of units. In the sma manner, emergency equipment
should be solely for ER use only;
IX.2
Rotation in the Emergency Room should be primarily service oriented. Hence
seminars and training on Value Reorientation, Rights of Patients, Client Satisfaction,
Art of Communication etc. are suggested topics during orientation;
IX.3
The Emergency Room shall be manned by no less than a second year resident
up. If ever there will be first year resident he/she should not be a front-liner;
IX.4
All residents manning the Emergency Room in addition to all health personnel
should have formal briefing by the Head of the Emergency Room;
IX.5
All medical personnel should have undergone Advanced Cardiac Life Support
in addition to the Basic Life Support before being assigned to the Emergency Room.
Likewise, all administrative personnel shall undergo Basic Life Support;
IX.6
Respective Departments have administrative supervision over those rotating in
the Emergency Room however the Head of the Emergency Room shall have technical
supervision over the said personnel.
X.

GUIDELINES IN TRANSFERRING EMERGENCY ROOM PATIENTS

X.1Attending physician in consultation with the senior resident of the Emergency Room
or the senior resident of the service makes the decision in transferring the paitent
based on the capability limitation of the hospital;
X.2Only the senior resident or Head of the Emergency Room Department should inform
the patient or relative as to the reason for transferring the patient and have them sign
on the space provided in the Hospital Referral Form #1 (no nurse, no intern, no first
year resident should be authorized to inform the patient or relative);
X.3Attending physician should fill up the necessary papers for transfer and brief the
Senior House Officer Or Department Head.;
X.4Senior House Officer/ Head of Emergency Room should make the call to the Senior
House Officer/ Head of Emergency Room of the receiving hospital. Receiving
hospital should be chosen based on capability of the hospital. The telephone lines
should be used in discussing the patienr and not the radio communication located in
the ER of all hospitals (This is reserved for emergency and disaster calls);
X.5Transport the patient by an ambulance and properly accompanied by a resident with
the official referral slip and laboratory and x-ray results if available. Acknowledgment

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form should be filled up and kept by the transferring hospital (see attached Hospital
Referral Form #2);
X.6In case there is no hospital to receive the patient and the only reason for referral is no
vacancy and not capability, the patient should be observed for not more than six hours
after which there should be final disposition, that is, to admit the patient. In the
meantime, the patient should be properly monitored, managed and correspondingb
chart should be issued;
X.7The transfer coul be done in both ways, that is, tertiary hospitals could also transfer
patients to secondary hospitals to decongest the hospitals and/ or make available beds
for tertiary cases that will come or be transferred.
XI.

GUIDELINES FOR INTER-HOSPITAL REFERRAL OR REQUEST FOR

PROCEDURE
XI.1
The service senior resident or the service consultant will recommend
procedures needed by an inpatient;
XI.2
Fill up Hospital Referral Form # 3 to be signed by the Head of Department or
Designate, and approved by Hospital Director or Designate;
XI.3
Social service of referring hospital should assess and classify the financial
status of the patient, and at the same time source out and make funds available. The
Social Service should have an updated list of all hospitals and corresponding available
procedures including their rates.
XI.4
The Attending Physician should coordinate with the hospital about the
schedule and preparation of the patient.
XI.5
Conduct patient by an ambulance with a resident;
XI.6
Receiving hospital to fill up the acknowledgment report (Hospital Referral
Form #3).

XII.

GUIDELINES FOR TRANSFERRING INPATIENTS

XII.1
The Attending Physician or the Service Consulatant recommends transferring
of patients already admitted in the hospitals;
XII.2
Prepare Form #4 to be signed by the Attending Physician and approved by the
Deaprtment Head;
XII.3
Social Service should fill up the Patients Classification and Justification;
XII.4
Attending Physician should coordinate with the receiving hospital about the
necessity of transferring the patient and the schedule of the transfer;
XII.5
Transfer patient by an ambulance with a resident;
XII.6
Referring hospital to fill up the acknowledgment receipt (Referral Form #4)
and receiving hospital gto sign. Detach this portion to be kept by referring hospital.

XIII. TRANSFERRING OF PATIENTS DURING DISASTERS AND EMERGENCIES

In times of disasters, emergencies or any mobilization of the ILHZ Disaster Units in
anticipation of mass casualties, the rules and procedures will be unsuitable in Emergency
Referrals described above. In such cases the following procedures will be followed:
XIII.1
All General Hospitals are designated as receiving hospitals to accept victims
of disasters; they have the option to transfer patients even within their capability to
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decongest their emergency rooms and for them to prepare for victims that will be
brought in;
XIII.2
All other hospitals should accept cases being transferred even without the
proper calls as required. In these cases, they will be informed through the radio
communication via the Operation Center (OPCEN) of the DOH-CHDCV?
XIII.3
The announcement and the termination of the disaster will be announced by
the OPCEN of DOH. Once it is lifted, everything will revert back to the usual
procedure described above.
XIV. IMPLEMENTING MECHANISM
XIV.1
Management
At the national level, the overall management of the referral system shall be
the responsibility of the Department of Health-Bureau of Local Health
Development/ Office of Health Facilities (OHF);
At the regional level, it shall be the responsibility of the Center for Health
Development through the Local Health Support Division (LHSD) & Licensing
and Regulatory Enforcement Division (LRED);
At the provincial level, the Provincial Health Team Office (PHTO), through
the DOH Representatives shall provide updates and advise ILHZ Boards and
municipal Local Health Boards on DOH policy guidelines and standards;
At the ILHZ Level, the Technical Management Committee shall provide
technical advice and recommendations to the Governing Board and catchment
facilities regarding health referral system and other matters concerning health
of the catchment areas.
XIV.2
Supervision, Monitoring and Evaluation
Periodic monitoring and evaluation of the progress of the implementation of
the Policy Guidelines on Referral System shall be established, institutionalized
and integrated in the Program Implementation Reviews (PIRs);
Models of good practice shall be documented and disseminated to
stakeholders of the ILHZ catchment areas;
Quarterly reports shall be submitted by the ILHZ hospitals to PHTO-CV,copy
furnished LRED of the CHD every first week of the first month of the
succeeding quarter;
The ILHZ TMC shall evaluate and propose policy changes to the ILHZ
Governing Board;
The Medical Director/ Chief of Hospitals,through the chief of clinics shall
administer these regulations and submit quarterly reports to CHD-CV;
The different Department Heads especially in the ER of the ILHZ hospitals
shall directly the implementation of these procedures at the hospital level;
hecshall report to the director through the chief of clinics.
XV.

EFFECTIVITY CLAUSE
This Administrative Order shall take effect upon the approval of the Governing Board,
subject to change as the need arises.
Prepared by:
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ABIGAIL DANICA SORIANO-BATTUNG, RN, RM, MSN

DOH Representative
Reviewed by:
EMMANUEL ACLUBA, MD, PHA
Chairman, Technical Management Committee
Approved by:
HON. DELFIN T. TING
Chairman, Metro Tug. Governing Board
Cc:
ELENA T. TULAUAN,RN,MSN

MA. GRACELYN P. DELIM,MD,MPH

LETICIA T. CABRERA, MD,MPA

Cluster Head

PHTO-Cagayan

OIC-LHSD Chief

EDWARD A. ALBANO,MD,MPH
OIC-Director III

TITA N. CALLUENG,MD,MPH,DTM&H
OIC-Director IV

MHOs&COHs of MT-ILHZ

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ANNEXES

DATE &
TIME
REFFERRED

NAME
OF
PATIENT

A
G
E

S
E
X

COMPLETE
ADDRESS

IMPRESSION
(Given by
Referring Facility)

REFERRED
FROM

REASON
FOR
REFFERAL

METHOD OF
TRANSPORT/
COMMUNICATION

RETURN
SLIP
(returned or
not)

Sheet 1 Monitoring Form for Incoming Referrals

------------------------------------------------------------------------------------------------------------------------Sheet 2 Monitoring Form for Outgoing Referrals

DATE AND
TIME
REFFERRED

NAME
OF
PATIENT

A
G
E

S
E
X

COMPLETE
ADDRESS

MEDICAL
IMPRESSION/
DIAGNOSIS

REFERRED
TO

REASON
FOR
REFFERAL

METHOD
OF
TRANSPORT

RETURN
SLIP (returned
or not)

------------------------------------------------------------------------------------------------------------------------Sheet 3 Quarterly Report Form for Incoming Referrals (per municipality)

AGE

SEX
BARANGAY
M

REFERRE
D FROM

SPECIFIC REASON FOR REFFERRAL

MEDICO
LEGAL

PRIORITY
FOR
ADMISSION
(for hospitals only)

OPD
CASE

OTHERS

CLASSIFICATION OF CASE
MED

PED

OBGYN

SURGERY

0-11
1-4
5-13
1449
5064
65 &
up

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Top Ten Leading Referred Cases (for all facilities)

No. of Cases

1._________________________________________
2._________________________________________
3._________________________________________
4._________________________________________
5._________________________________________
6._________________________________________
7._________________________________________
8._________________________________________
9._________________________________________
10.________________________________________
TOTAL NO. OF REFERRED CASES:

___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________

REMARKS:
________________________________________________________________________________.
________________________________________________________________________________.
Prepared By:
Approved By:
_______________________________
_________________________________
(Signature)
(Signature)
--------------------------------------------------------------------------------------------------------------------------------------------------

Sheet 4 Quarterly Report Form for Outgoing Referrals (per municipality)

AGE

SEX
BARANGAY
M

REFERRE
D TO

SPECIFIC REASON FOR REFFERRAL

MEDICO
LEGAL

PRIORITY
FOR
ADMISSION
(for hospitals only)

OPD
CASE

OTHERS

CLASSIFICATION OF CASE
MED

PED

OBGYN

SURGERY

0-11
1-4
5-13
1449
5064
65 &
up

Top Ten Leading Referred Cases (for all facilities)

No. of Cases

1._________________________________________
___________
2._________________________________________
___________
3._________________________________________
___________
4._________________________________________
___________
5._________________________________________
___________
6._________________________________________
___________
7._________________________________________
___________
8._________________________________________
___________
9._________________________________________
___________
10._________________________________________
___________
TOTAL NO. OF REFERRED CASES: _________ TOTAL NUMBER OF RETURNED SLIPS_________
REMARKS:
_____________________________________________________________________________________.
_____________________________________________________________________________________.
Prepared By:

Approved By:

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_______________________________
(Signature)

_________________________________
(Signature)

Figure 1 Operational Framework: Comprehensive Two-Way Referral System

Community

BHS
1st LEVEL PRIMARY HEALTH CARE

RHU

MUNICIPAL/
DISTRICT
HOSPITAL

PROVINCIAL
HOSPITAL

MEDICAL/
REGIONAL
CENTER

PRIVATE
HOSPITAL
2nd LEVEL PRIMARY HEALTH CARE

3rd LEVEL PRIMARY/

SECONDARY CARE

4th LEVEL TERTIARY LEVEL OF CARE

5TH LEVEL TERTIARY LEVEL OF CARE

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Elements of Successful Referral:

Consent of pt
Clarity of purpose of referral
Completeness of required information
Open line of communication
Pt education and empowerment
Acceptance by the physician and institution
Performance of the tasks required by the referral
Feedback by the referred physician or institution

Patient Referral Form should contain:

Pts data: name, age, sex, etc

Clinical abstract :Hx,PE
Dxtc procedures done and results
Problem/assessment
Reason for referral
Additional data/findings
Work-up done and results
Final Dx
Management and opinion
Medicines given, if applicable
Comments/ suggestions including prognosis/ outcome

Roles and responsibilities of Referring Physician:

Should know whta, when, whom, and where to refer

Accomplish referral form with all ne essary information
Explain to pt rationale for choice of doctor/hospital, preparation, expected cost,
possible outcome of referral
Facilitate scheduling and transport of pts
Secure result of referral

Roles and responsibilities of Consultant Physician:

Respond promptly for a request for consultation

Report in detail all pertinent findings and recommendations to the referring doctor
and may outline opinion to the pt
Communicate w/ pt and his family about what they should know regarding the
medical conditions
Return the pt to the referring doctor
Not to attempt by word or deed, to usurp or undermine the primary physicians
role

Current Issues of the Referral System:

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Insufficient Facilities: old/non-functional, downgrading, poor management

Inadequacies of Health Personnel: lack of personnel and competencies, poor
attitude
Inadequate Systems: lack of administrative policy on RS, non-utilization of
referral
forms,
no
downward/feedback
referral,
absence
of
information/communication system
Community Factors/perceptions: lower level provide poor service, lack of
information of services available and the referral network, proximity to higher
level facilities
Political Environment: lack of legislative support to referral system, referral to
higher level facilities by politicians, low priority on health

Role of Health Centers and Hospitals in a Referral System of ILHZ:

GUIDING PRINCIPLES FOR DETERMINING THE DISTRIBUTION OF

TASKS BET. FIRST CONTACT LEVEL AND FIRST REFERRAL HOSPITAL:
1. What is not done at the health center should be done at the hospital and vice
versa
2. Overlaps to be avoided
3. The Health Center is the place where the synthesis is made and responsibility
lies for providing comprehensive, integrated and continous care
4. The hospital function is one of back-stopping
5. The first contact level unit has the overall responsibility of taking charge of
the pts
6. Every aspect of health care has technical and human relations. As a rule, when
human relations are more important and technique less so, the health center is
a better place than a hospital. When the human relations aspects are marginal,
and technique more important or complicated, the hospital is a better place

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